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Licking County Democratic Club Membership Form

Yes, I want to support Democratic efforts in Licking County. Count me in!

________ Individual Membership ($20.00 before March 2008; $25 after March 2008)

________ 2008 Gold Package ($100.00 before March 2008; $125 after March 2008) includes 2 memberships and 2 tickets to the 2008 Jefferson-Jackson Dinner

________ Yes, you may automatically place Democratic yard signs in my yard each year!

Please make check payable to Licking County Democratic Club.

Please print!

Name ________________________________________________________________

Address _______________________________________________________________

______________________________________________________________________

Email Address _________________________________________________________

Phone # ______________________________________________________________

For the 2008 Gold Package, complete the following for the second LCDC member.

Name ________________________________________________________________

Address _______________________________________________________________

______________________________________________________________________

Email Address _________________________________________________________

Phone # ______________________________________________________________

Thank you! Please return this form along with your check to:

Ann Rader, Treasurer
Licking County Democratic Club
c/o Licking Count Democratic Party
15 W. Church St.
Newark, Ohio 43055